Identifying and Treating Uncomplicated Corneal Abrasions
James L. Moeller, MD; Sami F. Rifat, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 8 - AUGUST 2021
Athletic activities cause up to 10% of all eye injuries in children1 and account for 25% of severe eye injuries.2 The sports most commonly associated with eye injury are baseball, basketball, tennis, and ice hockey,1 but eye injury can occur in any sport.
Most eye injuries (71% to 95%)1,2 affect the anterior globe, and most of these are nonperforating. Corneal abrasions make up approximately 83% of all nonperforating anterior globe injuries.1
The cornea is a very thin structure, with a normal central thickness of 0.5 to 0.65 mm. It is composed of five layers. An uncomplicated corneal abrasion is an injury to the outermost layer of the cornea, the epithelium. These injuries tend to heal well without scar formation.3 The most important component in treating these injuries is accurate diagnosis, as any injury to one of the deeper layers can result in permanent scarring. Serious injuries, such as deep cuts, should be referred to an ophthalmologist at once.
Athletes will usually come off the field reporting that they were struck in the eye or that they feel a foreign body in the eye. Typically, the patient's eye is painful. Other symptoms may include increased lacrimation, photophobia, and blurred or decreased vision. History is very important, because some mechanisms are more likely to produce severe injuries than others.
Common injury mechanisms include being struck in the eye by an opponent's finger, fist, or elbow. Such low-intensity impacts often cause superficial injury, but impact from a ball, puck, stick, or racket tends to be of higher velocity and is more likely to cause severe injury. In addition, many athletes wear inappropriate eye protection or sunglasses while playing, and lenses may shatter, dispersing glass fragments that can lodge in the eye. To avoid this possibility, sports-specific custom eye protection should be worn. Questions about contact lens use and the athlete's normal visual acuity should also be asked. Athletes who wear contact lenses may get dirt or dust under the lenses, then rub their eyes and create an abrasion.
The examination begins by assessing visual acuity. Acuity can be tested on the field by using a hand-held eye chart or having the athlete read newsprint-sized writing held about 16 in. (41 cm) away (equal to roughly 20/40).
Extraocular muscle (EOM) activity and pupillary light reflex can be assessed quickly and should be documented. EOMs are assessed by having the athlete visually track the examiner's finger through the six cardinal directions of gaze: lateral, medial, superolateral, superomedial, inferolateral, and inferomedial. Shining a light directly into the eye should cause reflex pupillary constriction. Shining the light into the uninjured eye should cause constriction of the pupil of the injured eye (consensual light reflex). Both EOMs and papillary light reflex should be normal in uncomplicated corneal abrasion. Abnormal findings, such as cranial nerve injury or an entrapped ocular muscle (seen in orbital blowout fractures), require immediate evaluation by an ophthalmologist.
Obvious abnormalities, such as the presence of hyphema (blood in the anterior chamber of the eye), alteration in the shape of the pupil, or obvious leakage of aqueous humor, also indicate more serious injury. These patients should likewise be seen by an ophthalmologist immediately.
If the history and symptoms strongly suggest the presence of a foreign body, the patient's eyelid should be everted to look for the object (figure 1). Finding a small foreign body may be difficult without proper lighting and a magnifier, and the athlete may need to be moved to the training room or locker room for this procedure.
The hallmark of corneal abrasion is an epithelial defect that stains with fluoroscein (figure 2). The best way to evaluate the cornea for a defect is with a slit lamp, but this is not possible on the playing field or in most training rooms. Many physicians will instill an anesthetic eye drop before introducing fluoroscein, but this is not absolutely necessary. With the athlete looking up, fluoroscein is introduced with a sterile strip into the pool of tears in the inferior cul-de-sac.
Next, the eye is viewed using a cobalt blue light or Wood's lamp. Magnification can help but is not absolutely necessary. Using these instruments, a corneal abrasion appears as a greenish-yellow fluorescent defect in the epithelium. As noted, this test may require moving the athlete to the locker room or training room. If a question exists about the depth of the injury, or if there is suspicion of a penetrating or perforating injury, ophthalmologic consultation should be sought at once.
The three main treatment objectives are controlling pain, decreasing the likelihood of secondary infections, and promoting corneal reepithelialization. Our treatment of uncomplicated corneal abrasion includes the use of antibiotic eye drops and close follow-up, usually within 24 hours after injury. Use of other medications, such as ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) or mydriatics, is generally based on the individual athlete's pain level. We do not use eye patches on uncomplicated corneal abrasions.
Anesthetic eye drops, although often used to expedite the initial examination, should not be used for long-term treatment or control of pain associated with corneal abrasions and should not be given simply to allow return to play. Ophthalmic NSAIDs are effective in controlling pain that is associated with corneal abrasion.4,5 These medications decrease pain, photophobia, and foreign-body sensation and allow for earlier return to play without causing significant adverse effects or delaying healing.
Eye patches, which were once commonly used for pain control, have fallen out of favor. Some studies have shown that patients who are treated without eye patches may experience less pain6,7 and an increase in healing time6,8 than those treated with eye patches. At the very least, there is no difference in pain level and healing rates between using the eye patch and not using it.9
Epithelial injuries of the cornea tend to heal rapidly. In fact, there may be no residual evidence of injury at the 24-hour follow-up visit. Slit-lamp examination should be done to confirm healing, rule out associated iritis, and determine that no infection has begun. If these conditions are met, and the remainder of the eye exam is normal, the athlete may return to play. If the lesion does not improve or worsens, we recommend referral to an ophthalmologist.
Many eye injuries in sports can be prevented with the proper use of eye protection. In fact, the incidence of ocular injuries in sports, such as youth ice hockey, has declined since face masks and eye shields became mandatory.10 Rule changes (eg, elimination of high-sticking in ice hockey) can also play a role. Despite these advances, team doctors must be able to adequately evaluate ocular injuries.
Dr Moeller and Dr Rifat are family physicians at Sports Medicine Associates, PLC in Auburn Hills, Michigan. Dr Moeller is chief of the division of sports medicine at William Beaumont Hospital in Troy, and Dr Rifat is head team physician at Oakland University in Rochester, Michigan.
Disclosure information: Drs Moeller and Rifat disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.